Sen. Ryan Silvey is no fan of the Affordable Care Act.
Yet the Republican from Kansas City has become the legislative champion of a key component of what’s more commonly known as Obamacare — expanding eligibility for Medicaid.
He’s floated multiple plans over the last year that would add roughly 300,000 Missourians to the federal health insurance program for the poor.
Each time, he’s run headlong into a brick wall of opposition.
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“There’s a problem, and I’m trying to fix it,” Silvey said. “If no one is going to come up with their own solutions, I’m going to keep offering alternatives.”
His latest idea aims at trying to win over the Republican lawmakers who have vowed to fight any effort to implement the federal health care law in Missouri. Silvey wants Washington to let Missouri turn its Medicaid system into a block grant program.
It’s an idea conservatives have been pushing for years at the federal level. Its loudest proponent was 2012 GOP vice presidential nominee Paul Ryan. Silvey says it would give Missouri the flexibility to implement changes to Medicaid long sought by Republicans, such as work requirements to receive aid.
“Republicans in Washington want to block grant Medicaid,” Silvey said. “There needs to be a test case. Let Missouri be the test case.”
But just as in previous efforts, opponents aren’t budging.
“We are told there are all these conservative ways to expand Medicaid,” said Sen. Bob Onder, a Republican from Lake St. Louis. “I’m sorry, but putting 300,000 able-bodied Missourians on a welfare program is not conservative, no matter what bells and whistles are put into the program.”
The politics of Medicaid expansion in Missouri have always been complicated.
To be eligible for Medicaid in Missouri currently, a non-elderly adult must have a dependent child and can earn no more than 19 percent of the poverty level — roughly $3,700 a year for a single mother with two children.
Under the Affordable Care Act, states that expand Medicaid eligibility to those earning up to 138 percent of the poverty level can initially receive full federal funding for that group, with the federal share gradually scaling back to 90 percent.
Without expansion, Missourians earning between 19 percent of the poverty level and 138 percent qualify neither for Medicaid nor federal subsidies to help them purchase private insurance.
Around 200,000 Missourians fall into that coverage gap. Silvey doesn’t love the idea of expanding Medicaid but says this gap is a massive problem lawmakers must address.
Democrats have pushed the hardest for expansion. So have some traditionally Republican groups such as the Missouri Chamber of Commerce and Industry. They argue that expansion would provide coverage to uninsured Missourians and that doing so would inject billions of additional federal dollars into the state’s economy.
On the other side are conservative activists and lawmakers who believe it’s unwise to add to the national debt while putting more people in the care of a social safety net. A group of Republican senators has vowed to filibuster any bill that would expand eligibility.
That fight won’t likely be needed. Leaders in both the House and Senate made it clear that there will be no debate over Medicaid expansion this year. But they have made time for bills repealing portions of the Affordable Care Act, such as a hearing held Wednesday on legislation suspending an insurance company’s license if it accepts federal subsidies for policies sold through the federally-run marketplace.
“That’s the most disappointing thing,” said Andrea Routh, executive director of the Missouri Health Advocacy Alliance. “We can’t even get our legislature to debate expansion or hold a hearing.”
But even Routh, whose organization has been among the loudest proponents of Medicaid expansion, can’t support Silvey’s block grant legislation.
Medicaid is an entitlement program, meaning everyone who is eligible is guaranteed a spot. The federal government pays most of the costs. In return, it requires states to cover certain groups of people and to provide specific benefits.
A block grant would effectively end this approach and provide states with annual lump sums of funding. States would be in charge of establishing benefits and defining who is covered.
Silvey’s bill would create a joint committee consisting of five House members and five Senate members who would come up with benefits and eligibility requirements. The bill lays out a few potential points of discussion, including private option insurance plans, work participation requirements and standards of personal responsibility.
Critics of this approach fear it could ultimately result in reductions in benefits and fewer people receiving coverage.
“If you have a block grant where there is a ceiling on the amount of money, the number of people may increase,” Routh said. “But you don’t get any more money for those people.”
The only way to really have a Medicaid block grant is for the federal government to restructure the program, said Patrick Ishmael, policy analyst with the conservative Show-Me Institute. Short of that, he said, any effort at the state level is unlikely to result in any real changes to the system.
The legislation mentions several reforms Missouri would seek to implement if the federal government granted a waiver, but simply listing those ideas doesn’t carry much weight, Ishmael said.
“The bill talks about things that could be discussed, but discussing reform isn’t reform — especially if the federal government is already taking ideas off the table,” he said, pointing to a list of ideas compiled by the Kaiser Family Foundation that have been rejected by the federal government.
In effect, Ishmael said, Silvey’s bill could be used to “guarantee Obamacare’s expansion but would not guarantee key reforms.”
Silvey insists that the federal government is becoming increasingly comfortable with granting waivers to states that agree to expand Medicaid eligibility. So far, five states have received a federal waiver allowing them to implement the expansion in ways that do not meet federal rules and still access enhanced federal matching funds.
“If the federal government is going to be flexible,” he said, “then let’s just jump straight to the end and give (Missouri) full flexibility.”
His ideas may not end up winning over his colleagues, but Silvey says he’ll keep pushing.
“The coverage gap is a problem,” he said. “This is one possible solution for it. I’m open to any solution. It doesn’t have to be my idea. But we need to start addressing this now.”